Violence in Psychiatry

9781316135839

Focusing on violence from assessment, through underlying neurobiology, to treatment and other recommendations for practice, this book will be of interest to forensic psychiatrists, general adult psychiatrists, psychiatric residents, psychologists, psychiatric social workers and rehabilitation therapists.

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Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

Introduction

In recent years, the evidence base to support the use of pharmacotherapy in personality disorders has grown. A number of recent systematic reviews examining this issue concluded that, of the available treatments, mood stabilizers and atypical antipsychotics demonstrated the most clinical benefit [1–3].

A number of atypical antipsychotics, including quetiapine [4–6], aripiprazole [7], and paliperidone [8], have been found to be effective in improving the clinical symptoms of borderline personality disorder (BPD) [9]. In addition to displaying a positive effect in BPD [10–14], olanzapine also reduces symptoms of psychosis and depression in schizotypal personality disorder [15]. Similarly, low-dose risperidone reduces the severity of schizotypal [16] and borderline [17] personality disorders.

Of the atypical antipsychotics, clozapine has shown promising results in the treatment of personality disorder. Clozapine, an atypical antipsychotic with a wide-ranging receptor profile [18], is used in the treatment of schizophrenia. Studies have shown that it is of particular benefit in treatment-resistant schizophrenia [19], with response rates between 30% and 60% [20–22]. Clozapine was found to significantly reduce incidents of self-harm and aggression in a case series of seven female patients with severe BPD [23]. Other studies, including a case report [24], two case series [25,26], and a prospective open-label study involving 15 patients [27], replicated similarly positive results.

Clozapine is also widely known for its anti-aggressive effects [28,29], which have most commonly been demonstrated among schizophrenia patients [30–35]. In a randomized control trial comparing clozapine, olanzapine, and haloperidol, all three drugs showed similar antipsychotic effects; however, clozapine showed a significantly better effect in reducing violent incidents, thus indicating its specific anti-aggressive effects [36].

As clozapine has been shown to be of benefit in certain subtypes of personality disorder and also in reducing aggression in schizophrenia, it is reasonable to hypothesize that it may improve the clinical severity and also reduce aggression and violence in patients with antisocial personality disorder. There is currently limited research in this area.

We present a case series of seven men with a primary diagnosis of antisocial personality disorder (ASPD) and who also scored high on psychopathy (as assessed by a validated psychopathy checklist) [37,38]. All patients had a significant history of serious violence and were commenced on clozapine treatment while being cared for in a high-security hospital.

Colin A. HodgkinsonLaboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA

Brian J. HoloydaDepartment of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA

Matthew J. HoptmanSchizophrenia Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, Department of Psychiatry, New York, USA, and University School of Medicine, and Department of Psychology, City University of New York, New York, USA

K. Luan PhanDepartment of Psychiatry, University of Illinois College of Medicine, Mental Health Service Line, Jesse Brown Veterans Administration Medical Center, and Departments of Psychology, and Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, Illinois, USA

Barbara E. McDermottDepartment of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA

Jonathan M. MeyerDepartment of Psychiatry, University of California–San Diego, San Diego, California Department of State Hospitals, and Patton State Hospital, California, USA

John MonahanSchool of Law, University of Virginia, Charlottesville, Virginia, USA

Matteo PardiniDepartment of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, and Magnetic Resonance Research Centre on Nervous System Diseases, University of Genoa, Genoa, Italy

Katalin A. SzaboDepartment of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA

John TullyDepartment of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Stephen C. P. WongDepartment of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, School of Medicine, University of Nottingham, Nottingham, UK, and Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia